27217 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO ..ILDIbli-ei,KUHIBUAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 27217
BUILDING PRO.IECTIDENTIFICATION
BUILDING
ADDRESS: SANITARYNO. APPLICATION SURMM17PAIL DATE
Oko�-+�� �Q / ✓� �/� UlsITM /Cry 11�3 1.091#
O ER NA PFI E:
CONTRACTORS E: LIC NO:
z z--"e r N/C CONTROL#
• ARCHIThUDILNGINEER: MC NO: ADDRESS: ❑
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEF. BUILDING PERMIT INFO
/Al 1. V lair 04 "W 606/ PERMIT ISSUANCE BLDG ELECT ,o MECH
LICENS CONTRACTOR'S DE LARATION APPLIANCES-RESIDENTIAL IAF/ JOB DESCRIPTION Ih6yb
QWz I hembyaffirn Nat l amlicensW underprovisions of Chaprer9(commeneingwilh
u100❑ Sectionremdof Division of the Business and Professions Code,and my license is in PANELS ��
a�+U fullnse Chdaffoct. UP TO 200 AMPS .7//�/\I
6 uJ License Class Li<.p
to=to Data Cono-actor 201-IOW AMPS
7ONZ ARCHITECT'S DECLARATION OVER IOOO AMPS SQ.PT.FLOOR AREA E/SQ.IT.
O Z—❑ I understand my plans shall be used as public words.
r 4 t uJI SIGNS ELECTRICAL a—,/
h7d Licensed Professional 's,
(�
OWNHR-BUILDER DECLARATION SPECIALCIRCUIUMISC.
KOgF I hereby affirm that I am exempt from the Contractor's License Lew for Ne
m 3 q m following reason.(Secll m III LS,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
F'�w� which requimsape.am wmauci,.Rer.improvedemolish,or repair my dirdebrt
T� prior to its issuance,also requires the applicant!orsuch permit to fileasignedawement POWER DEVICES
ty p G O that he is licensed pursuant in Ne provisions ofthe Contractor's License law(Chapter
qqa� 9(commercial,with Section]00(l)of Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
W m or that he is exempt therefrom and the basis for thealleged exemption.Any victim mot f�
I-. Q
Section 7031.5 by any applicant for a permit subjects NOUTLETS-SWITCHES-FIXTURES a
e applicant to a civil penalty of 01,7-9.
^� G not more Nun rive hundred full...(S5W).
m ❑ I,asownerofthepmpny,ormyemployaswiNwagesas Neirsolecampensmion, NEW RESIDENTIAL ELECfIi _SQ.PP'. STORIES TYPE CONSTRUCTION
q _ sdidothe work.andtheswcwmis no,imenJedoroffered for call,(See.]044,Bear...
and Professions Code:The Contractors License Law does not apply to an owner of
property wbobuildsorimMoves Nemon,and whodoes such work Initiation through his OCC.GROUP RES.UNITS
rwnemployees.pmvidW that such improvements manotintendedorofPomd hostile.IL
however,the building or improvement is sold within oneyeerofcompletion,the owner- TOTAL:
builder will have the burden of proving that he did not build or impreve for purpose of
snle.).
Les
❑ ownerof the propcny,amexclusivelyconvaming wiNlicensW contrrctors to QTY. PLUMBING PERMIT EE ILOOD ZONE APN
combat,has pvi(Sec.7044.Business and Pfmfessloms Code:)The Cm uractm's
License Lawdoes not apply to m ownerofpropeny whobuilda mongooses,heremn,and PERMIT ISSUANCE
who contracts far such projectso-
withaconm,or(s)Iicenud pursuiu
uo,he Conor
oacte
Licensimse Law, ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
La
❑ I am exempt under Sec. B&PC for this meson BACK FLOW PROTECT.DEVICE T DFEES
RECEfPI'#
S YN
Owner Data
WORKMAN COMPENSATION DECLARATION
ION DRAINS-Fl.00R,BOOP,AREA,COND. SCHOOL TAX YN
❑ Ihertby nffirn,ha,lhave ac<nificate of comeat to self-insum,ora«nifeme ofRECEIPT'#
Workcrs'Compcnsa,ion lmurance0racmifiedcopy thereof(Sec.38W,Leb C.)wbicM1 FIXTURES-PER TRAP PARK FEE YN_
covers all employee's under this panni,. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT#
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER4(EA) PLANCHECK PEE
❑ CartifiedcopyisherebyfumiNal.
❑ Certified copy is filed with lie city impecdon division. GREASE/INDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
Mi.seelionneW not be completed ifthe permit is furone hundred doftrs(SIW) SEWER-SANITARY-STORM EA.20DFT. ENERGY FTE
or less.)
I certify that in the perfomwce,ofthe work for which this permit is Issued,l shall WATER HEATER W/VENT/ELECfR
no,employ my person in any manntt so as to become subject to the Workers PAID
Compamiamn Levenf Celifomia. Data WATER SYSTEM/TREATING Data Receipt#
O z-+ Applicmt
z 0 NOTICE TO APPLICANT:If,afar pukingthis Certificate Of Excmprim,you should NEW RESIDENTIAL MAIL SQ.FT. TOTAL,
become subject to Ne Workers Compensation provisions of the labor Cede.you must
a '
forthwith comply with such provisions orthis permit shall be deemed revoBUILDING FF.Eked. / 7 a —
4i1 Q CONSTRUCTION LENDING AGENCY SEISMIC FEE 7a
I hereby affirm that them is a construction lending agency for the performance of M1
V O the work for which this penrd,is issued(Sec.301 Civ.C.) TOTAL: ELECTRIC ME J
0 landr'.s Name PLUMBING FEE. \�U
Pander's Address QTY. MECHANICAL PERMIT FEE
1. I agr that I have reed Nie application and amm Out the above information is S
crmn. agree to comply with all city and county ordinance and show laws relining toPERMIT ISSUANCE MECHANIGLFEE
,0 buildingconswction,andherebyauthorizerepresentativesofthiscirytoemeruponthe CONSIRUCI'IONTA% 36
V z ahwe-mentioned property for impaction purposes. ALTERORADDTOME-CH.
(We)agree a save,indemnify and keep harmless the City of Cupertino egeimr
Iiabilities,judgmems,costs undexpareas which may irony way accrue ag.last said City AIR HANDLING UNIT(TO 10.0p CFM) S
in mnsc cmf the granting of this Permit. AIR HANDLING UNIT(OVER 10,00)CFN)
Signmum of Applicana/Commuchm, / Data EXHAUST HOOD OVIDUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IW,"BTU) Data Receipt#
Will the applicant or future building occupant store or handle hazardous materiel IIP.ATING UNIT(OVER I W,(100 BTU) TOTAL:
m defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safe,,
Cade,Smite 25572(n)P
El Yes Cl No VENTILATION FAN(SINGLE RISID)
BOILER-COMP(31 IF OR I W,OOB BTU) fy1SAUABNCE DATE
Will tire an,
e applicorfutumhuilding occupamm
uuequipmeordevices which eros, II�r
hazurlou.s air contnminers as defined by Ne Bay Area Air Quality Management BOILER-COMP(OVER I00d"BTU)
Distdm) In'� >n
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.Pf. A,tl q� 19g5
I have reed the harmdmm materials requirements under Chapter 6.95 of the I Jx�
California l leulbh&Safety Code,Sections 25505,25533 and 25534. (understand Nat Y tar Lir
if the builJing Aocs nn,currently have a tennnt,,M1at it is my¢sµmsibility to notify Ne /N/t
occupant of Ne requirements which mus,W me,prior to issuance of n Cerditrute of V
Occupancy.
Owner or vuthomed agent Data TOTAL: ISSUED BY:
OFFIC